Quote of the Day

T.R. Reid's "The Healing of America"

The Healing of America

My global quest demonstrated that America’s approach to health care is unique in the world for a good reason: No other country would dream of doing things the way we do. So it’s clear that we can’t fix the basic problems by tinkering at the margins of our existing system. Any proposal for “reform” that continues to rely on our fragmented structure of overlapping and often conflicting payment systems for different subsets of the population will not reduce the cost or complexity of American health care. Any proposal that sticks with our current dependence on for-profit private insurers – corporations that pick and choose the people they want to cover and the claims they want to pay – will not be sustainable.

To put it simply, the United States does well when it comes to providing medical care, but has a rotten system for financing that care. We need a health care system that permits the strong facets of American medicine to flourish, makes their benefits accessible to everybody, and does it in a cost-efficient way. As we’ve seen, this is not impossible. All other rich countries have found financing mechanisms that cover everybody and they still spend much less than we do. We’ve ignored those foreign models, partly because of “American exceptionalism” – the notion that the United States has nothing to learn from the rest of the world. In health care, at least, that old mindset is clearly losing its sway. Americans are coming to realize that the other rich countries are getting more and better medicine, for less money, than we do.

Another reason Americans tend to ignore the valuable lessons we could take from the rest of the world is that we have been in thrall to conventional wisdom about health care overseas. Thus we conclude that the foreign approaches would never work here. In fact, as I found on my global quest, much of this conventional wisdom is wrong. A lot of what we “know” about other nations’ approach to health care is simply myth.

Comment:

By Don McCanne, MD

In “The Healing of America” and in last year’s PBS Frontline presentation, “Sick Around the World,” T.R. Reid has demonstrated how other nations have higher performance health care systems that take care of everyone and at a much lower cost than in the United States.

Other nations have adopted one of a few rational models of health care financing, though with variations. The basic models are Bismarck (Germany, France, Belgium, Switzerland, Japan), Beveridge (Great Britain, Italy, Spain, most of Scandinavia), and national health insurance (Canada, Taiwan, South Korea).

The United States has combined these models into our patched-together system of financing health care. Our components are Bismarck (employer-sponsored plans), Beveridge (VA, Indian Health Service), and national health insurance (Medicare). But we’ve added one more model that Reid discusses: out-of-pocket for the uninsured (Cambodia, Burkina Faso, rural India, rural China). Reid makes a strong case that this dysfunctional, fragmented financing system is in a large part responsible for our very expensive mediocrity.

Which model for the United States?

The out-of-pocket model is certainly not suitable, and the Beveridge model would have very little support only because Americans are uncomfortable with the concept of government ownership of the health care delivery system.

National health insurance, based on an improved model of Medicare, would be very popular once established, and would enable us to reach our goal of affordable, high-quality care for everyone. It is the least expensive, most equitable, most efficient, and most effective model of reform.

T.R. Reid and others such as Uwe Reinhardt believe that Americans are more likely to support the Bismarck model based on private health plans. But they emphasize that our U.S. plans with a business mission would have to be transformed into European-style plans with a service mission. The superficial similarities between the U.S. and European private insurers belie the stark differences in their missions. Just imagine the probability of the highly-compensated U.S. insurance executives and the institutional investors that own their companies stepping up to lead this essential transformation. Fat chance. It is difficult to share the faith that T.R. Reid and Uwe Reinhardt have in the insurers doing the right thing.

But the biggest problem is not with the private insurers; it’s with Congress. They have decided to move forward with our patched-together system, primarily by expanding the use of U.S.-style, business-model private plans. We will be forced to use inadequate subsidies to purchase private plans that are too expensive and that provide inadequate protection in the face of medical need. This is a program that will expand expensive mediocrity – hardly the solution we seek.

An improved Medicare for all is what America would really want, if only the people were better versed in policy science. It’s our job to see that they become so.

(T.R. Reid will be a featured speaker at the PNHP Annual Meeting in Cambridge, MA on Saturday, October 24. Meeting information is available on the PNHP website at www.pnhp.org).